PLACE OF INJURIES OF ELBOW JOINT IN THE STRUCTURE OF PRIMARY PERMANENT DISABILITY AMONG UKRAINIAN POPULATION

. Place of injuries of elbow joint in the structure of primary permanent disability among Ukrainian population. Naumenko ., . Despite the rapid development of orthopedics consequences of elbow injuries have a significant proportion of unsatisfactory treatment results until now. Owing to comprehend the sources of disability doctors could determine drawbacks of treatment and regulate rehabilitation program for patients with elbow injuries better. The purpose of the study was to investigate the structure of primary permanent disability due to elbow injuries among the Ukrainian population. The study was made on annual reports of Regional centers of medical and social expertise and the Center of medical and social expertise of the city of Kiev for 2018. During the reporting period a disability group due to upper extremity injuries was established totally for 1 211 patients in age over 18 years, among them 195 people had consequences of elbow traumas. That caused an intensive prevalence rate of 6.22 cases per 1 million of adults. Male patients (70.8%) and patients in working age (94.9%) prevailed among people with disability. 10.8% of patients were determined as people with disability without a revision period after the primary examination on medical and social expertise commission. The causes of primary permanent disability were domestic injuries (90.8%), occupational injuries (5.0%), injures during military service and battle injuries (2.1%) and disability since the childhood (2.1%). Structure according to disability groups showed the next distribution: 90.3% – the 3rd group, 9.2% – the 2nd group and 0.5% – the 1st group. Consequences of elbow injuries which led to primary permanent disability were caused by bone fractures (61.5 %), elbow contractures and elbow ankyloses (19.0%), injuries of an ulnar nerve (8.7%), traumatic amputation at the elbow level (6.2%), forearm dislocations (3.1%), open wounds of elbow (1.0%), elbow ligaments ruptures (0.5%). Patients registered as disabled with a revision period during the

На умовах ліцензії CC BY 4.0 Abstract. Place of injuries of elbow joint in the structure of primary permanent disability among Ukrainian population. Naumenko L.Y., Zub T.О., Mametyev A.О. Despite the rapid development of orthopedics consequences of elbow injuries have a significant proportion of unsatisfactory treatment results until now. Owing to comprehend the sources of disability doctors could determine drawbacks of treatment and regulate rehabilitation program for patients with elbow injuries better. The purpose of the study was to investigate the structure of primary permanent disability due to elbow injuries among the Ukrainian population. The study was made on annual reports of Regional centers of medical and social expertise and the Center of medical and social expertise of the city of Kiev for 2018. During the reporting period a disability group due to upper extremity injuries was established totally for 1 (3,1%), рани ділянки ліктьового суглоба (1%), пошкодження зв'язок ліктьового суглоба (0,5%). Пацієнти, яким групу інвалідності при первинному огляді на медико-соціальній експертній комісії встановлено з терміном переогляду, мали достатній реабілітаційний потенціал, який дозволить їм відновити функцію ліктьового суглоба та верхньої кінцівки в цілому.
Injuries of elbow joint occupy a leading position among the upper limb traumas. Fractures of elbow region make about a third part of all fractures of upper limb, often cause to unsatisfactory results of treatment and in 18-29 % of cases injured people are recognized as disabled [1,2]. The main reasons of that are a complex anatomy of bone and soft-tissue structures, a long period between trauma and surgery, diagnostic, tactical and technical mistakes during the surgical intervention [1], prolonged immobilization and propensity to heterotopic ossification which lead to early development of elbow stiffness [2,3].
An anatomical feature of the elbow joint is rather thin coat of soft tissues around the bone ends those ones provide both movements in ulnohumeral articulation and supination and pronation of the forearm.
Thereby injury of elbow can lead to significant impairment of the wrist joint and hand function.
Despite the numerous scientific papers which were dedicated to elbow injuries and methods of their treatment, the problem of permanent disability determination for these traumas was not investigated enough [2, 4]. Studying of primary permanent disability structure could help orthopedists to reveal severe injuries which caused permanent disability the most often and those ones which regarded by doctors as minor for treatment and thus are treated improperly. Also understanding of permanent disability reasons could assist in regulation of rehabilitation program for patients with elbow injuries. 22/ Том XXVII / 3 The purpose of the study was to investigate the structure of primary permanent disability due to elbow injuries among the Ukrainian population.

MATERIALS AND METHODS OF RESEARCH
The study was carried out on materials of the State Institution 'Ukrainian State Scientific Institute of Medical and Social Problems of Disability'. Data were received from annual reports about disability due to upper extremity injuries of Regional centers of medical and social expertise (disability determining centers) of city of Kiev and 24 Ukrainian regions, including parts of Donetsk and Lugansk regions which subordinate to Ukraine.
The research was conducted in accordance with the principles of bioethics set out in the WMA Declaration of Helsinki -"Ethical principles for medical research involving human subjects" and "Universal Declaration on Bioethics and Human Rights" (UNESCO).
Disability connected with the elbow region was studied in deep with using separate reports of centers of medical and social expertise. Patients were distributed into groups by age (under 39 years, 40-60 years, over 60 years), by gender, by cause of disability (domestic, occupational, injuries during military service and battle injury and disability since the childhood), by disability group (the 1 st , the 2 nd , the 3 rd ), by determination of the period of review (with or without one) and also by diagnosis according to International Classification of Diseases-10. Such traumas as fractures of the distal humerus and fractures of the proximal ulna and proximal radius, dislocations of a forearm and isolated ones of a radial head, soft tissues injuries particularly contusions, wounds, tears of elbow joint ligaments, injuries of ulnar nerve, elbow crushing, traumatic amputations of the elbow and consequences of elbow injuries e.g. elbow stiffness and elbow ankylosis were referred to the elbow region injuries.
Statistical analysis was performed using methods of descriptive statistics those are implemented in the STATISTICA 6.1 software (by StatSoft Inc., SN AGAR909E415822FA). Relative values were calculated (fraction of all injuries, injuries of upper extremity and its segments those caused disability during 2018) with 95 % Confidence Interval (-2M; +2M). If the lower Confidence limit was less than 0 the Confidence Interval was found as statistically unreliable one and we did not give it after relative values. Also the intense prevalence rates of the listed injuries per 1 million of adults were calculated [5].

RESULTS AND DISCUSSION
On the 1 st of January 2018 population of Ukraine was 38 486 392 people, among them 31 361 687 people were at the age over 18 years (adults) and 22 436 027 of them were at age between 18 and 60 years (working age) [6]. In our calculations we used number of adults because these people had being observed with centers of medical and social expertise.
Total number of disabling traumas (rank S and T by International Classification of Diseases-10) which led to primary permanent disability in 2018 was 13 571 cases (prevalence 432 per 1 million of adults). Among them the number of upper limb injuries was 1 211 cases (8.9 (8.4; 9.4)%) and 195 cases were related to elbow region injuries (1.4 (1.2; 1.6)% of all traumas, prevalence 6.22 per 1 million of adults). In spite of such a small proportion in the whole structure injuries of elbow region have a great social significance. Moreover they can restrict an ability to work and self-service and decrease the quality of life.
Among In 17 cases (8.7 (4.7; 12.7)%, prevalence 0.54 per 1 million of adults) of injuries of ulnar nerve (S54.0) were the cause of primary disability. Ulnar neuropathy leads to restriction of hand function due to excluding interosseus muscles, lumbrical muscles and thumb adductor function and in such a way decreases possibility of hand grips and restricted pinching and holding of things between tips of the thumb and II-V fingers [9]. Traumatic amputations at the elbow level (S58.0, prevalence 0.38 per 1 million of adults) were determined in 12 cases (6.2 (2.7; 9.7)%). The feature of such injuries was a structure of distal humerus region of the anatomical widening at the place of condyle which determined a club-shaped form of a stump. So, as all prostheses had a so called "dead zone" necessary for placement of prosthetic modules [10, 11] exarticulation of the forearm was not likely to make if someone wanted to have an amputation stump adapted well for cosmetic or functional prosthetics. Patients after traumatic amputation at the elbow level usually need reconstructive surgery of stumps in the future if the formation of the functional adapted stump was impossible during the primary care after injury [12]. Elbow contractures (28 cases, 14.4 (9.4; 19.4)%, prevalence 0.92 per 1 million of adults) (M24.5) and elbow ankyloses (9 cases, 4.6 (1.6; 7.6)%, prevalence 0.29 per 1 million of adults) (M24.6) in perverse position were the reasons of disability determination in the distant period after elbow injury. One of the cause of such conditions was heterotopic ossifications [13].
According to the findings the typical patient first registered to be disabiled due to the consequences of elbow region injury has the following features: male person of working age with an unilateral bone fracture or some consequence of elbow injury in distant period which led to elbow contracture or elbow ankylosis in perverse position.
Furthermore every 10 th person with registered permanent disability has irreversible changes of anatomy or function of elbow by the moment of the first examination in Medical and Social Expertise Commission. Thus these patients were determined as the disabled people without a revision period. On the other hand 9 of 10 people require active medical rehabilitation, particularly for physiotherapy (electrical procedures, exercises) and occupational therapy to improve function or to adapt to restricted range of movement in the elbow joint [4].

CONCLUSIONS
1. In Ukraine in 2018 195 people were primary registered as people with disability due to consequences of elbow injuries (prevalence 6.22 per 1 million of adults).
2. The typical patient was working-age male person with a unilateral injury in the main due to a fracture of bones those formed the elbow joint.
Funding. This research received no external funding.